Hello, everyone, and welcome to our presentation on 2021 E&M changes with clinical examples sponsored by the American Society for Gastrointestinal Endoscopy and the ASGE Foundation Beyond Our Walls campaign. My name is Michelle Akers, and I will be your moderator for today's call. The presenter for today's call is Kristen Vaughn. Kristen is a national consultant with over 16 years of coding and billing experience. This includes gastroenterology, pulmonary critical care, immunology, rheumatology, hematology, and hospitalist specialties, plus seminar instruction, auditing, and on-site consulting. Her background includes extensive experience in a teaching university, and she currently is a full-time consultant trainer with Asmuller Consulting. Her presentations have included organizations such as AGA and ASGE, and she is a certified professional medical auditor and certified ICD-10 trainer. She is the co-author of several workbooks and programs specific to gastroenterology. She also answers the coding email for ASGE. Before we get started, just a few housekeeping items. There will be a question and answer session at the close of the presentation. Questions can be submitted at any time online by using the question box on the right-hand side of your screen. If you do not see the question box, please click the white arrow in the orange box located on the right side of your screen. Please note that this webinar is being recorded and will be posted on GILeap, ASGE's learning management platform, in approximately one week. As a registrant for this webinar, you will have access to the recording. The slides for this presentation will also be in GILeap and are available for downloading in the handout section on the right side of your screen. At this time, I would like to turn the webinar over to Kristen. Kristen? All right. Thank you, Michelle, and welcome, everyone, to the webinar today that we're going to go over the 2021 E&M office changes. All right. So some of the things that we're going to cover today, we're going to review, we're going to do an overview of the E&M changes by the AMA. So we're just going to kind of summarize what happened on January 1st with the office documentation guidelines. We're going to also review time documentation in 2021 because that is a big area that was changed for the office setting. I'm going to provide you a clinical example. So we get questions a lot that, well, how do we document this? So it's good to show you examples and kind of put that into play. Then one of the biggest areas we'll focus on today is that medical decision-making table. So the medical decision-making table changed a little bit for the office setting as far as problems addressed, data, and overall risk of the patient. So we're going to go into those details in depth. Then we're going to take a look at some clinical examples with medical decision-making, and we're going to do a little bit of a comparison. So we're going to give you a clinical example, and then we're going to show you what it looked like last year, the level of service, versus what it looks like this year. Kind of putting those different hats on to see, did the level of service really change or was it affected? And sometimes it is. So again, I'm going to go over some clinical examples with decision-making. And then just last but not least, some practice pearls, some tips on documenting in the office setting. All right, so we're going to go through the summary of the E&M changes. All right, so what happened? In most of the next few slides that I'm going to go through, you probably are familiar with us already since it's now almost the middle of February. So you've probably been seeing some guidelines, and your EMRs, your electronic records, have been updated to support these changes, hopefully. But one of the more important things is making sure that your providers, or if you're listening in, you're a provider listening in, just making sure what are the things we need to document, what has changed, et cetera. So keep in mind, this only impacts office setting. So these are codes specific to 99201-205 and 99211-215. That's the only thing that this impacted. ER, inpatient, any of those were not changed. None of those CPT codes were changed as far as definitions go. But this is office setting. So the first thing that they did is they deleted 99201. It's your new patient level one, reason being underutilization, which obviously, those of you listening in, you're gastroenterology, you're a specialty practice, you don't see straightforward patients. By the time they go in CGI, they're pretty well, something's going on, we do a workup, et cetera, on the patient. So not really hurt. I don't think many practices are hurt with the fact that 99201 has been deleted. There are new guidelines specific to 202-215. So looking at those codes, those are your new patient office visits and your established patient office visits. There's changes in the scoring made up for 99202-215, and I will explain that in just a second. Again, changes to the medical decision-making table. There are also changes to the time thresholds associated with each of these visits. So last year, it was one specific time that you had to meet. This year, it's a range of time, and we will look at that as well. Now keep in mind, time will not be associated with CPT 99211. And if you don't know what that is off the top of your head, 99211 is a nursing visit. So if your patient comes in to get their vitals checked, they come in to get medication teaching, those things done by the nurse, which is considered an incident-to service, there is no time. We can't bill by time for that nursing visit. All right. So this slide shows you the instructions in your CPT book. So those of you, hopefully all of you listening in, have an updated CPT book for 2021. If you don't, you need to order one as soon as possible. There are a lot of changes in the E&M section that you need to read. And that's also just part of compliance, part of compliance for practices that you have updated coding books in the office and the clinics, et cetera. So here are the changes that you're going to see when you go throughout the CPT book. Obviously, we're not going to detail these changes because there's not enough time. All right. So you're going to see some changes to the common guidelines regarding all E&M services. Then they're going to break down, you'll see the breakdown for hospital ER consults, nursing facilities, custodial care, and home services. Then you're going to see all that new advice, which I always say it's the green section. So anything in green is an update, a new change. So you're going to see the guidelines for office and other outpatient services. And that is a section overview explaining the new guidelines for these codes. The differences, so they're going to give you the comparison of what we were used to to what we have now, revised existing guidelines, terms and definitions, the new table for office, the new medical decision-making table for the office setting. And then time, there are also instructions for time guidelines when more than one provider performs part of the E&M service. And I'll touch on that in just a second. And then again, revision of the medical decision-making table to include new table for office scoring information. All right, so those are some of the things that you're going to see new or revised in your 2021 CPT book. All right, so these are the biggest changes, okay, for your office. Okay, keep in mind, the whole time we're talking about this, it's office, office, office, office. So history and physical examination is still required. Okay, I'm going to say that again, still required, but will not be part of the scoring to determine the level of medical decision-making. The level will be based on decision-making or total time alone, okay? So it's just what it says. The provider should do a pertinent history, do a pertinent exam, but that assessment and plan, the medical decision-making or the time of the encounter is what supports the level now. All right, the table of risk, okay, there's a little change in those. I'm not going to read this because we're going to go into this information in detail. Decision-making has to be contained in the documentation, has to. All right, so we're going to first talk about time, documentation and billing requirements for the office. Then we're going to segue into decision-making, medical decision-making, okay? So it's kind of one or the other. You're going to determine your level either by time or the decision-making aspect of it. So in regards to time, okay, time reporting effective 2021, clinicians who want to base their visit reporting on time will be able to count time they spend performing a variety of activities on the day of the patient's visit, including time spent updating clinical information in the records. This is really important. This includes only face-to-face and non-face-to-face time that they personally spend on a patient care and only on the day of the visit, okay? So what are some of those things that can be included in that time calculation? Well, preparing for the visits, reviewing tests, performing a medically appropriate exam and evaluation, ordering medications, test procedures, documenting in the medical record, all of that, okay? All right, this is the definition. So this is what you're going to see in your CPT book, okay? Total time on the date of the encounter, and again, they reference 202 through 205 and 212 through 215. It says, for coding purposes, time for these services is the total time on the date of the encounter. Face-to-face and non-face-to-face time spent by the provider, okay, does not include time in activities normally performed by clinical staff. So they make it clear that this is the provider time. This is not your nurse's time, you're not your medical assistant's time, it is provider time. And the time has to be spent on the day the patient is seen, okay? If you spend 20 minutes reviewing records the evening prior to, that does not count. All right, so here are the time thresholds that are for this year, okay? So remember, 201 is deleted. So 202, so that's a level two new patient visit, 15 to 29 minutes, then a level three new patient, 30 to 44 minutes, level four new patient, 45 to 59 minutes, level five new patient, 60 to 74 minutes. Again, there is no time threshold associated with the nurse visit, so you go to 99212, which is your level two follow-up, 10 to 19 minutes, level three follow-up, 20 to 29 minutes, level four follow-up, 30 to 39 minutes, level five, 40 to 54 minutes. And you might be thinking, the time's increased, what the heck? Well, they did increase, meaning, okay, so I'll give you an example of increase, okay? 99214, all right, if you look at 99214, right now, the change is 30 to 39 minutes. Last year, it was 25 minutes. So you might be thinking, what the, you know, why did it increase? Well, it increased because you are allowed to now count everything you do in the care of the patient that day, okay? Prior to this, when it was last year, 99214 was 25 minutes, but that meant face-to-face time with the patient and the provider only, okay? So yes, it increased a little bit, and now there's ranges, but there's a reason for that. All right, so we're going to look at a clinical example, okay? This is an established patient of the practice, was on vacation in Florida, and experienced severe symptoms, flare, of her UC pancolitis, which prompted her to present to the ER at the Florida hospital. The patient was admitted for a four-day stay until her symptoms improved. Patient was instructed to follow up with her gastroenterologist as soon as she returned home. Patient was seen in follow-up by her GI the next week. The physician spent 15 minutes on the day of the visit reviewing the hospital records, another 20 minutes obtaining a current history and exam. The physician decided then to move her Remicade infusions from eight down to six to help control her flares. The provider then spent an additional 10 minutes documenting in the medical record recording history, exam, and assessment and plan of care. All right, so here's what the note looks like. Chief complaint, here for follow-up of her recent pancolitis flare, all right. HPI, pleasant female, here for follow-up of the flare. She was vacationing with her children in Florida when she experienced severe abdominal cramping, diarrhea, and bleeding. She presented to the hospital due to the severity of her symptoms. Since being treated at the hospital, her symptoms have improved and they're back to baseline. Past family social history, no change since last updated in the chart. Review of systems, patient has occasional episodes of abdominal cramping and diarrhea, but this is her typical baseline, no other symptoms reported, okay. So this is a very good interval history, okay. This is a follow-up patient. The HPI contains the information as to what has happened since last seen or, you know, what prompted her to be seen today. If past family social history has not changed, you don't need to regurgitate that information as long as it's somewhere in the patient's medical record. Review of systems, also, notice there's not a 14 review of systems documented here. There doesn't need to be. We only need to document what's related to the chief complaint, all right. So here's the examination for the patient. General, appears well, is pleasant, no acute distress. GI, no abdominal pain, no tenderness, bowel sounds active. That's it, okay. So, again, not a nine head-to-toe organ system exam. That's not necessary, okay. It's okay for you to document, examine, and document those pertinent elements. All right, so here's the impression. Patient presented for the follow-up after recent hospitalization in Florida for her UC flare, including severe abdominal pain, diarrhea, blood in the stool. Her symptoms have greatly improved since hospitalization, but due to those flares, I've recommended her Remicade infusions be shortened down to six weeks from the current eight. This was discussed with the patient in detail, which she agrees. We'll order the new infusion schedule. Patient to follow up with me in three months or sooner if symptoms worsen, okay. All right, so the breakdown here by time. Spent 15 minutes reviewing records, 20 minutes in history and exam, and an additional 10 documenting the visit and adding new orders for her infusion schedule. So based on the 15, 20, and 10, that's a total time of 45 minutes. That is a level five, 99215 by time. If you think about this patient by medical decision-making, it doesn't support a five at all. She doesn't even have any current symptoms, stable chronic issue, et cetera, okay. So by time, though, it's supported. Now, if you're thinking, well, I don't, how am I going to be able to remember these times and how to break them down and this, that, and the other, okay. There are no concrete guidelines out there yet that say this is how time should be documented. So until it's confirmed or there's guidelines out there, the provider could also choose to say 45 minutes of total time was spent, but you must include the details for the timed encounter. Meaning you can't just record your visit and then slap a time at the bottom and say good to go, okay. There has to be supported details. So as you can see above, we know that there was an extensive chart review that had to be done. We know how much time the visit took, and we know how much time the provider documented that visit, okay. So it's good to have the breakdown, but you can say total time as long as you support those details. Now, I don't have the information in here because it's actually a CPT clarification, and this has to do with all shared visits. So whether it be the hospital or the office setting, if you have provider, if you have physicians working with PAs or nurse practitioners, we get this question a lot. Well, what happens with the time associated with a shared visit, okay. So shared visit is when they both see the patient, both document, all right. CPT instructs that as long as these are unique different times, so it's not the time that both of them sit down and see the patient, they're distinct times. Your advanced practitioner can document their portion of time, and then in an addendum to support the shared visit, the physician can also include their additional time. Those times can be totaled for the level of service that's billed, all right? Again, as long as it's distinct time, OK? It can't be their time spent together. It's 20 minutes by one and maybe 15 minutes by the other. But they can combine their time and bill that appropriate level of service by that time threshold. OK, so we've looked at time. We've looked at the guidelines for time documentation. We've looked at a clinical example. Let's then shift our focus to medical decision making, OK? So let's say we're not going to bill by time. We don't need to bill by time. We're going to level our service based on that assessment and plan or medical decision making. This is a table. This has not changed. This was the same last year. This just tells you the overall medical decision making and the level that is supported. So your level 2s are considered straightforward. Level 3s are low complexity. Level 4 is moderate complexity. Level 5 is high complexity. Again, that was last year. It's the same thing, all right? So what has changed a little bit is the three columns of medical decision making, OK? So the first column of decision making is what we now call problems addressed, OK? So last year, if you remember, if you do any kind of audits or you're looking at visits, or even if you're a provider and you're trying to select that level of care, you're clicking those boxes to come up with your level in the electronic medical record, all of this verbiage has changed. So last year for the office, we based our first column on new problems versus established problems, worsening problems, workup, no workup, those things. That's changed. Now we are looking at the type of problem addressed, OK? That is going to determine whether the problem is straightforward, low, moderate, or high, OK? So straightforward is considered a self-limited minor problem. I don't think we're going to see a lot of those for GI. Low is considered two or more self-limited or minor problems, one stable chronic illness, or one acute uncomplicated illness or injury. Moderate is considered one or more chronic illness with mild exacerbation, progression, or side effects of treatment, two or more stable chronic illnesses, one undiagnosed new problem with uncertain prognosis, one acute illness with systemic symptoms, or one acute complicated injury. High, it's chronic illness with severe exacerbation. So look at the difference between moderate and high. Chronic with mild is moderate. Chronic with severe is high. So it's very imperative. It's very important for your providers. If the patient really has a severe exacerbation, progression, or side effect of treatment, they document, they use the term severe. It's just a best practice recommendation, all right? One acute or chronic illness or injury that poses a threat to life or bodily function. So that would probably be a patient that comes in with a problem so significant, you're probably sending them to the ER or you're admitting them, okay? So that is the table for problems addressed in the office. All right, problem addressed, this is just CPT's definition of what a problem addressed is, okay? You evaluate it or treat it at the encounter, okay? So if you just say coronary artery disease or long-term current use of anticoagulants per cardiology, that means you did not address that problem, okay? So you have to address it, assess it. Also, referral without evaluation does not include, is not counted as problem addressed. Now, you might evaluate the problem and determine that they need to be seen by cardiology or pulmonary, that's okay. That is, you still addressed it. But if all you say is chest pain, see pulmonologist, that's all you say, you know, that is not counted as a problem addressed. If you say chest pain, do not, I do not feel that it is GI-related in nature, will refer the patient on to pulmonologist to rule out any significant pulmonary disease. That is addressed, okay? So be careful, make sure that assessment and plan is very specific as to what you did and what you addressed. All right, now we're gonna look at data. And you might be looking at this slide going, wow, that's a lot of information. And it is, it really is. What they've done with data. So last year, it was more of a point system. You got one point for lab, one point for imaging, two points for reviewing previous records, all these points. And you added up all the points and it determined your overall complexity of data. Now it's broken into categories, okay? So category one, two, and three is going to depend upon the definition of those categories and how many of those you did. That's gonna determine whether it's straightforward, low, moderate, or high, okay? So we're gonna break these down. Straightforward just means like one test was reviewed and or none, there was no data today. It could have been just a quick follow-up of GERD, patient needs are refilled, they're doing well. We have no reason to order any tests. We have no previous records that we need to review those things. That is straightforward. Low, okay? In order to meet low, you have to meet one of the two categories. The first category is test and documents. So you have to perform at least two of these bullets. Either review external records and order a new test or you can order two unique tests, et cetera. That would meet limited or low, okay? Or let's say you don't do anything from category one, but you do take some information from someone other than the patient, which is independent historian, okay? That's considered low. Moderate means you have to meet one of the three categories. So again, test and documents, category one. Independent historians, category two. Three is discussion of management or test interpretation, okay? So again, category one for moderate, you have to meet three, okay? So you have to do order three unique tests or you have to review external records and order two tests. Okay, so those are some of the things. Or you could do external records and gather information from an independent historian, okay? Or let's say you don't do anything from category one and you just do independent historian and discussion of management or test interpretation. That's moderate, okay? The difference between moderate and high, same categories, one, two, and three, but you have to meet two of the three categories in that combination. So it's very imperative for your providers going forward. When they are ordering any sort of testing, whether it's labs, imaging, they need to document the specific test because this goes by each unique test. So we're gonna kind of go through, well, what do you mean by each unique test? We don't know what that means, okay? So this is the CPT definition. It says tests or imaging lab, psychometric or physiological data, a clinical lab panel. Okay, so if you order a basic metabolic panel, that is one test. The differentiation between a single and multiple unique test is defined in accordance to the CPT code set. So basically that says, let's say you order three unique tests. If each one of those tests have a different CPT code associated with it, you get credit for three tests. But if you order a panel that is one CPT code, that's only one test. That's how you have to determine it. And again, the provider is gonna have to be that specific and that detailed in order for us to give them credit for it. One clarification, too, for external records. So notice one of those categories or one of those bullets under the first category of data was reviewing outside records. They have clarified that it has to be external records, external providers, external facilities, external healthcare organizations. So you pulling up your clinic visit from last year or six months ago does not count. That does not count as an external record because it's your medical record. It also does not count if provider A in the practice saw the patient six months ago and your provider B. If you pull up their note, that could maybe be part of your time documentation for the visit if you're billing by time, but it can't count for data because it's not someone else outside of your organization's note. All right, independent historian. Okay, so this is someone that, let's say the patient has a mom, dad, brother, sister, aunt, uncle there with the patient because the patient maybe has dementia or they're just a poor historian. That is information gathered from that family member that's supplemented from the patient, okay? So you're getting further information from them that you can't get directly from the patient. That involves patient care. Independent interpretation means that you are doing, you're pulling someone else's report outside of the practice and you're doing an interpretation of it, okay? So let's say the patient had a CT done at the hospital last month and you're pulling that report up now to get your personal interpretation of it, okay? It does not, and I'm going to make this clear, independent interpretation does not count if you haven't billed for that, if you have billed for that interpretation internally, okay? So if it's a capsule that maybe a provider did a month ago and now you're seeing the patient in clinic and you're pulling that up, you can't get credit for data because you've already billed the capsule interpretation component. It's kind of like they look at it as double dipping, okay? Appropriate source means, so if you ever see appropriate source referenced, this means professionals who are not healthcare professionals but may be involved in the management of the patient, so an attorney, a parole officer, case manager, teacher, okay? So tips, when the provider is reporting a separate CPT code that includes interpretation and a report, the interpretation and a report should not count towards the decision-making when selecting a level of office or other outpatient service. So I just explained that. So they make it very clear in their definition of the CPT book. When a physician or other qualified healthcare professional is reporting a separate service for discussion of management, okay, it's not counted. All right, now the last column to decision-making for the office is the table of risk, okay? So this table actually is now pretty vague. If you compare it to last year's table of risk for the office, they gave us examples. We were pretty well, you know, we knew kind of what we were dealing with as far as the level of risk. This now is all on the provider's plate, indeterminate, minimal, low, moderate, or high, all right? They don't even give us examples of what a straightforward or low-risk patient is. They literally say minimal risk of morbidity from additional diagnostic testing or treatment. Low is low risk of morbidity from additional diagnostic testing or treatment. Now, moderate, they do give a few examples. Prescription drug management, decision for minor surgery with identified patient or procedure risk factors. And I'm gonna clarify, diagnostic endoscopy is considered minor surgery, okay? Minor surgery is considered anything with a zero or 10-day global package. Diagnostic endoscopies have zero, all right? Major surgery without identified patient or procedure risk factors. So if the patient needs surgery and that surgery has a 90-day global, it's a major surgery. There's also a new, this is a brand new item under moderate risk. Diagnosis or treatment significantly limited by social determinants of health. High risk of morbidity, still drug therapy requiring intensive monitoring for toxicity. Major surgery with identified patient procedure risk factors. Emergency major surgery or do not resuscitate or deescalate care because of poor prognosis. And then a very new one for high risk is decision for hospitalization. All right, so I'm not gonna read what risk is and what morbidity is. This is information for your providers to review and for you to know the definitions of, okay? The biggest thing I'm gonna say about the risk is if the patient is high risk for something, document that. If they're moderate risk, document that. If they're low risk, document that, okay? Otherwise you're leaving it up to an auditor on the payer side to determine if that level five is truly supported because you did not use those terms. You did not document risk factors. You did not document, again, the fact that the patient is high risk, okay? So please use those terms. This is important for you to kind of go and look at these ICD-10 codes when we're dealing with social determinants of health. That's a new category. And we get a lot of questions like, well, what does that mean? Economic and social conditions that influence the health of people in communities, okay? So any of these code categories can be considered social determinants. So problems with employment, literacy, social environment, upbringing, support, psychosocial circumstances, environmental circumstances, okay? Obviously drug therapy requiring intensive monitoring. Those are just some of the examples for the table of risk. All right, so little changes there. All right, so now that we've broke down the decision-making table, we're gonna put this new decision-making table into clinical examples. And what I'm gonna do is I'm gonna show you the table from last year and what the level would have been. And then I'm gonna plug all that same scenario into a 2021 decision-making table so you can see the differences. All right, number one, this is an established patient. Assessment says IBS, which appears under control at this time. Plan, continue current dose of frequency of amytsia. Return in three months for reevaluation unless otherwise indicated. That's it, okay? All right, so last year we had one established problem, which is one point minimal. No data is minimal. Prescription drug management's moderate. You already have two minimums highlighted there. So the overall is straightforward, which is a 99212. Oh, but look at the new table. This is one stable chronic illness, which is actually low for problems addressed. Data's minimal still. Prescription drug management's still moderate. But look at this. You don't have two out of the three met. So how do you determine the level? You drop the lowest and pick the lowest, the one remaining, okay? Because it has to be met or exceeded, all right? Low in this scenario is met or exceeded because it's exceeded by the risk. So this is 99213. So last year it was a 212. This year is a 213. Okay, number two, this is another established patient. IBS, which appears under control at this time despite increased stress factors. Increased anxiety due to increased financial and work stress. Continue meds for IBS. Increase aminotryptoline. She is requesting psychiatric counseling, and I believe this would be beneficial for schedule an appointment, return in three months. All right, so this is considered two worsened problems, which is extensive. This was last year. No data, again, in prescription drug management against moderate. So remember, we dropped the lowest, picked the one in the middle. It's overall moderate, 214 last year. This year, it's actually considered moderate for presenting problem because you've got one or more chronic illness with exacerbation, progression, or side effects of treatment, okay? I don't think we can consider this high because there wasn't anything that said this is severe. All right, there's severe side effects. It's more of a mild or progression. So moderate, again, none for data. And then again, prescription drug management. So if you see here, you still have two moderates, still a 214, okay? So both tables supported 99214. Number three, new patient visit. Left upper quadrant abdominal pain, history of ulcer, onimeprazole, per primary care with no improvement. Left lower quadrant pain has been treated for diverticulitis with no change. Bentil has some relief. No evidence of diverticulitis on CT scan done, but showed a renal stone. Reviewed primary care records and hospital records. Details were in the HPI. Nausea with early satiety and indigestion. Plan, continue current medications, vental and increase emeprazole. Follow up with primary care regarding renal stone and left side pain. Gastric emptying scan. Follow up in one month. Okay, so now we've got a lot of data on this patient. All right, so last year, it was a new problem with a workup, all right, which is four points, high. Moderate for data, because there was a review of a CT scan, ordered a gastric emptying and reviewed records. And then prescription drug management. So we've got two moderates by data and risk. This is 99204, all right. Looking at it this year, we're dealing with at least an undiagnosed new problem with uncertain prognosis, which is moderate. Moderate for data as well. Okay, so that fell into the moderate category for decision-making when you looked back at all the categories. And prescription drug management. So we have moderate on each column. So that is 99204 by decision-making. All right, number four, new patient visit. So this is a chief complaint of diarrhea. 82 year old female with diarrhea for the last six months. She's new to our practice. She has up to five loose bowel movements per day, diurnal and nocturnal, watery type associated with mild abdominal cramping, not associated with fever, GI bleed, significant weight loss. Per patient, she took antibiotics for a week two months ago due to an upper respiratory infection. She denies any recent travel or other family members with similar symptoms. She drinks coffee daily. Previous colonoscopy report in 16 by Dr. K showed mild diverticulosis. Assessment, diarrhea. For the last six months, family history of colon cancer and sister has indications for colonoscopy. If lymphocytic colitis is proven on biopsy, then intercourt will be started. It is necessary to rule out C. diff or celiac disease. So plan is colonoscopy, check celiac panel, stool for C. diff, encourage hydration, avoid caffeinated beverage, and then the order specifically outline the types of tests performed. All right, so if you look at this last year, we definitely have a new problem with a workup plan, which is high. Review of records and ordering labs is multiple. And then diagnostic colonoscopy was considered moderate. So you've got two moderates for data and risk. That's a 99204. This year, you've got for your problem address, new problem with uncertain prognosis. We don't know why she has the diarrhea. We got to do further workup. We reviewed external records, and we ordered several different labs. That's still moderate. Diagnostic endoscopy is considered low, because there were no identified risk factors documented. But we still have a four based on problem addressed and data. So both 2020 and 2021 support a four. Number five, new patient. Patient has been losing weight for the past year, about 12 pounds. Last EGD showed normal esophagitis, mild gastritis. Colonoscopy was two polyps and diverticulosis. Patient had fecal incontinence, has sacral neuromodular placed five years ago, no longer helping. On Xarelto for DVTs. Patient had been noticing black stools for the past two to three months and a cult positive by primary care. She denies use of iron or Pepto-Bismol. She takes Imodium as needed for diarrhea once a week. Patient has early satiety, denies nausea, vomiting, denies chronic heartburn, history of MI with occasional angina, relieved by NTG. Progressive Parkinson's disease since 65 denies use of aspirin or NSAIDs. All right, so assessment. Fecal occult positive stool and melana, weight loss, early satiety, history of polyps, incontinence of feces, diarrhea, DVT, Parkinson's, so everything that they just went through. Okay, so what are we gonna do? What's the plan of care? So we've got, we're gonna do labs. We're gonna do procedures, high-risk EGD, high-risk colon, spoke with cardiologist who will see the patient next week for cardiac clearance and evaluate occasional angina. Also discussed stopping Xarelto two days prior to the procedure of clear to be scheduled outpatient, okay, since the patient is considered ASA-4. Also ordered a CT for the weight loss. All right, so last year by decision-making, definitely new problem with workup for high. Extensive for data, you had order of a CT, review and order of labs and speaking with a cardiologist. And then diagnostic endoscopy with risk factors is high. So this is overall a 205. Every column supported high complexity. It is a 204 now, okay, because you've got multiple chronic conditions and one new problem with uncertain prognosis, moderate. You did have extensive for the data, but diagnostic endoscopy is considered moderate only when risk factors are identified. That's no longer high risk. So you've got moderate total because you had moderate from the first and third column, 99204. All right, so again, we just broke this down that the difference between the five and the four and Y, okay. Number six is a new patient visit. Chief complaint is acid reflux. Lonnie is a 54-year-old female referred by Dr. X. She has a history of duodenal ulcers 15 years ago. She's had new reflux symptoms in the past year and is on Protonix. Recently, they have flared, denies any dysphagia. She has never smoked and rarely drinks alcohol. Impression, symptomatic GERD, EGD to rule out Barrett's. Patient verbalizes understanding. So last year, new problem with a workup. High, no data. Diagnostic endoscopy with no risk factors was moderate. So overall, you have moderate for decision-making 99204. But let's look at the table now. So this is considered a new problem with uncertain prognosis for the problem addressed, which is moderate, no data. Minor surgery with no risk factors is low. So this is a 99203 today. So again, last year, a diagnostic endoscopy was considered moderate risk. All right, 203 is low risk. It will fall under minor surgery with no risk factors. Okay, so it is imperative that your providers document everything reviewed. And again, documenting anything that impacts the decision-making, such as comorbidities, risk factors, if they're discussing risks of the procedure, et cetera, with the patient and what those risks are. Remember, they have to identify them. All right, last example, consultation. 49-year-old male seen in consultation at the request of Dr. Smith with occasional right lower quadrant pain for the past two weeks. The pain is worse with bowel movements and also notes occasional black-colored stools. Stool for GOYAC positive. Denies any associated fevers, chills, bloating, nausea, vomiting, or weight loss. Patient notes a history of hypertension. Family history is negative for GI diseases and malignancies. Patient is retired and has never used alcohol or drugs. The provider also had documented a 14 review of system and an eight organ system exam. So for the right lower quadrant pain and melana, we're gonna do EGD with colon on Friday for further evaluation of melana and right lower quadrant pain. Got differentials, prep instructions were given, risks of the procedure were discussed, all questions answered. All right, so 2020, we have a new problem with the workup, extensive. No data and diagnostic endoscopy with no risk factors moderate. So overall moderate level four consult. Guess what? It's the same this year. There were no changes to the documentation requirements for consults, okay? Their health still has to be a comprehensive history and exam and the medical decision-making would follow the 2020 guidelines. How confusing is that? Yep, they did not update. They specifically state this in CPT that documentation requirements for consults still have to be met as they were last year. Practice pearls, all right? Remember, history of present illness tells the story of the patient, whether new or established. Put all pertinent information in this area regarding current symptoms and abnormalities. Often your data component is in this paragraph. So if you do any kind of reviewing records, speaking to other providers, et cetera, it could be in there. It doesn't matter where it is in your note, it will be counted, okay? The impression and plan should also contain what you are addressing, what you think it might be, why you are ordering additional tests, procedures, et cetera, instructions to the patient and caregivers and any other recommendations. List all conditions that you are managing and or that play a role in the care of the patient. If not documenting, no one knows what you did or are doing. This is not just for supporting the level of service, but for medical necessity and preauthorization of tests and procedures, okay? Not only that, it is a medical legal document, okay? Even though the history and exam don't directly factor into your level, you still have to make sure that you document a chief complaint, all right? And they still have, all of the things have to be pertinent to the visit. So for example, if the patient comes in with abdominal pain, you would expect to see an abdominal exam performed and documented. Another example, if the patient comes in with elevated transaminase, a social history specific to drug and alcohol use should be documented as well as any family history of GI diseases or malignancy. So again, you have to make sure it's pertinent to the reason you're seeing the patient. So until you get a good system in place, we recommend you just utilize your templates. We expect that this is one part of E&M documentation changes. We expect to see changes in all the visit categories, but that's just subject to, we'll have to see, we'll have to wait and see. Train all providers to really focus on the HPI and impression and plan. It is not quantity, but the quality of the note. And remember, if decision-making does not support your level of care provider, build a visit based on total time for hospital and office locations. All right, that is the end of the webinar today. I'm going to send this back to Michelle for closing comments and Q&A. Thanks, Kristen. And we do have a few questions that have come in. But before we get to the question and answer session, a few notes about ASGE's coding and reimbursement-related resources available to you. This year, ASG is offering all four webinars for one low price, and you see the dates there. So make sure you spread the word and share with your GI team. At this time, we will have Kristen address some of the questions that have come in. As a reminder, you can submit a question through the question box. If you do not see the question box, click that white arrow in the orange box located on the right side of your screen. It'll be towards the bottom. So our first question, Kristen, is, if you have two acute uncomplicated issues, can that fall under moderate problem addressed? No, it would still be considered low if it's acute uncomplicated. The only way it would push it to a moderate is if you have a complicated, so acute complicated. And usually when they consider acute complicated, they're looking at, does a patient have systemic symptoms that maybe go with that, or extensive treatment that is needed? But if it's truly just two acute uncomplicated, it's still gonna be low, no matter if there's one acute uncomplicated or five acute uncomplicated. Thanks, Kristen. The next question is, if you order a test that you are billing for, where does that fall in decision-making? Can we get a data point for ordering, just not reviewing? Nope. CPT specifically states that if your practice is billing for any of those services, you cannot give, you cannot credit any aspect of the medical decision-making part because you're already billing for that service. Thanks. Our next question is, where can we find a list of medications requiring monitoring for toxicity? Oh, that's a good question. There is none. Okay, there is not one set list. There is one Medicare contractor out there, and I believe it is Noridian. It's either Noridian or Novitas. And those of you listening in, you're probably on several, under several different Medicare contractors. There is not one approved list out there. So what auditors typically look for is the provider documenting that specific medication and frequent monitoring, okay? Not once a year, not every six months, but frequent monitoring of labs, anything like that to check for specific issues. And the provider just needs to also say, you know, we are monitoring for toxic, Thanks. Our next question is, when selecting the moderate-risk category for prescription drug management, what is considered management? Does the provider only get credit when writing a new prescription, or do refills also count? All right, so Medicare has actually clarified this information, and they consider prescription drug management just that, management. So if you're the one responsible for writing the prescription, you get credit whether it's renewing it, refilling it, well, refilling it is renewing it, increasing it, decreasing it, starting it, et cetera. That is all considered prescription drug management. Thanks. Our next question is, can you provide an example of who would be considered an independent historian? In quotes. And how does the provider need to document this to ensure appropriate credit given? All right, so if the provider actually is speaking to someone other than the patient, so we kind of went through that example in the presentation. If they're speaking to, let's say the spouse, okay, because the patient has dementia, and they're gathering pertinent history elements from that person. It doesn't matter where it's documented. Typically, we see this documented in the HPI. The provider will say, per patient's wife, he has been experiencing abdominal pain and cramping, he's been going to the toilet a lot, et cetera. So again, if they document who they got it from and the specific information that they gathered, that is considered that historian. Thanks. And we have one last question. And that is, with the new E&M guideline changes to the outpatient setting, do you know if there has also been any changes with the SL-285 for visit prior to screening colonoscopy and documentation for those services? So far, we have not seen anything. So I've checked UnitedHealthcare's website, Cigna, Aetna, those payers that are, the bigger payers that follow the Affordable Care Act, they still have the S-0285 on their screening colonoscopy policies. There have been no updates that I'm aware of to any documentation changes. Thanks, Kristen. And one more. What is considered an undiagnosed new problem with uncertain prognosis as it relates to GI patients? So this, I consider this, so I'm an auditor. When I look to giving the provider credit for moderate, undiagnosed new problem can be abnormal LFTs that require further workup, any sort of symptom that requires a further workup, any sort of abnormality on CT, those are some of the more common undiagnosed new problem with uncertain prognosis that we see in GI. Thanks, Kristen. That was our last question. So I want to thank everyone for joining us today. We hope this information certainly is useful to you in your practice. If you have any questions regarding today's webinar, please contact the staff listed on the slide. As ASG has designated this webinar for a maximum of 1.0 AMA PRA Category 1 credits. And as stated earlier, the recording of this webinar will be available in approximately one week on ASG East. ASG East GI Leap for access to you. When visiting, you will complete an evaluation of the webinar and claim your credit. And it is important that if you did share as the paid registrant, this course or webinar with your team, that they register individually. If that was not the case, please email me, that's Michelle Lakers on that slide, so that we can get that taken care of because they would have to go into GI Leap in their own setup account to claim their credit. Otherwise they can't claim credit, just so you'll know. And this concludes our webinar. Stay tuned for more future educational opportunities from ASGE and thanks and have a safe and great day.

2021 E&M changes

Evaluation and Management

clinical examples

E&M documentation guidelines

time spent on patient care

medical decision-making requirements

level of service billed

problem addressed

data

accurate documentation